Laserfiche WebLink
' oRqufN c � • <br /> ?'- •P SAN JOAQUIN COUNTY FILE Copy <br /> y ENVIRONMENTAL HEALTH DEPARTMENT LOP <br /> 600 East Main Street, Stockton, CA 95202-30291 SITE MITIGATION <br /> d`� FOR <br /> Telephone: (209) 468-3454 Fax.'(209) 468-3433 Web:www.sia�ehd <br /> q ......::.NSP <br /> FOR WELLS AND <br /> WELL <br /> &BORIINGOPERMIT APPLICATION NO REMEDIATION C0 8 2010 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED EWRONM <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is Q�W�� ENTAL H <br /> Joaquin County Development Title,Chapter 9-1115.3,and the Standards of the San Joaquin county Environmental Health Department. E r kith'Ya, <br /> EA <br /> Site Location H Ottiti s4 (.L,.,6 (CZsr <br /> Crosk Street Cit <br /> Property (�le✓S P`'1•`�S ta..d ir•-�1by- �'_�fCJ/1u '/N� y :"71o�C-'ibn zip 152—�0._APNQ�''_.[E,S—G�'fi.. <br /> Owner Address a ^r TD lK;il D�rb� <br /> C-57 Contractor F �r,I It Y Z� Phone7 x�2•�d�•�$OS <br /> Z1'�%ti ro— address 319 Luv u n u nr cite_ c,� <br /> Consultant/Sub Cntr Y nYAC Lice Phone 9�-��1S-J`Sro <br /> `>✓ - ' C��2 Address3L! 1-C Vr'„1tr I-F I?d City IQ I All Lic cam/ <br /> Billable Party( I, je,ilcN G4w Phone Y)•S-�i/�%- �$ <br /> "p ddress - 3Y�){ ;v� Act Cit �- q - <br /> GIS Coordinates:X '�2�T A 9j� y � r J r J ���— y �� l t(zip /`'y52'3._ 'hone <br /> .CONSTRUCTION WORK TO BE PERFORMED: <br /> NEW WELUBORING(CPT,GEOPROBE HYDROPUNCH,HAND-AUGER,OTHER) <br /> QISOIL BORING IDs CiFcnrr B - yv v; �*- -7-,•, ` .- ` <br /> WELL IDs ,C J<Q / C `y�. ✓oL[/I., lC <br /> [IOTHER IDs <br /> TYPE # IT RING RING <br /> M INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 0 <br /> _❑EXTRACTION:Vapor/Water [IHAMMER/DRIVEN CASING THICKNESS 0 ❑ Yo E]IPLE CASINGS[I MULTI-LEVEL WELL CASING R _ <br /> r TYPE OF CASING: STEEL PVC OTHEE R <br /> _❑SOIL VAPOR PROBE El MUD ROTARY DEPTH OF GROUT SEAL <br /> _❑SOIL BORING TREMIE TYPE 70 BE USED: ❑AUGERS ❑HOSE PIPE <br /> W�tl ❑PUSH POINT(GP/CPT) GROUT SEAL PUMPED:❑Yes o(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> 22-A 1NJECTION LAr Sparge OMppj 0 HAND AUGER GROUT SPECIFICATIONS (MAXIMUM <br /> 1�/I <br /> -HER - Lf:$ ',OTHER: APPRO%.BORING DEPTH r r <br /> 71”( A= E ❑BOLTED TRAFFIC BOX OR >aTOVE PIPE <br /> COMMENTS: I I NDUCTOR CASING o❑Y s:Cas' g Dia. Casing Depth: Boring Dia:_ <br /> NOTE: OFFSI E WELLS 8, BOR G REQUIRE ACCESS AGREEMI R ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: <br /> #OF WELL(SI TO BE DESTROVEO DESTRUCTION METHOD-lCHECK ALL THAT APPLY) <br /> WELL IDs: ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT {� <br /> GROUTS ❑PRESSURE GROUT TO DEPTH OF FTBELOW SURFACE C <br /> TREMIE TYPE 7"O BE USED.❑AUGERS ❑HOSE ❑PIPE ❑EXPLOSIVES FROM io FT BELOW SURFACE <br /> COMMENTS ❑MUSHROOM CAP AT(>3 FT) FT BELOW SURFACE <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regulations,and II a licable Ca ifornia laws. <br /> Signed =� 7 u _ Title/Company SOJVPrintName o ^T ( Z r0 <br /> _ <br /> ate <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS DEP TMENT US <br /> WORK PLAN DATED 2M BY V <br /> APPLICATION ACCEPTED BY <br /> DATE ISSUED LU AREA Ib <br /> GROUT INSPECTION BY FINAL INSPECTION BY <br /> DESTRUCTION INSPECTION BY DATE <br /> __ <br /> COMMENTS/CONDITIONS: DATE <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# SERVICE RO# <br /> RECV'D BY DATE <br /> REQUEST PR# INVOICE <br /> 0 $122 x Z.•` SR# 1(/ <br /> 90 (/ <br /> eZz, �!, (�'�-i / R, # 6(1035 <br /> C-57 WC WAIVER _ 2900 � d <br /> EHD 29-oi 07i2B/10 C-57 LETTER OF AUTHORIZATION T IGN PERMIT ENCROACHMENT DOC <br /> ILE Y WELLPER P <br />